RICHMOND, Va. (WRIC) – The in-custody death of Irvo Otieno could have been prevented if not for “the complete breakdown of Virginia’s mental health crisis system and the Commonwealth’s culture of criminalizing individuals with mental illness,” per a disAbility Law Center of Virginia (dLCV) investigative report. The dLCV, a nonprofit group federally mandated as Virginia’s Protection and Advocacy organization, released its 20-page investigative report into Otieno’s death in August with recommendations aimed at helping avoid similar deaths. The group said it found “a cascade of systemic failures” that led to the death of Otieno, a 28-year-old Black man who died while in the custody of Henrico County sheriff’s deputies at a state mental hospital during a mental health crisis in March 2023. Otieno's death was ruled a homicide and several individuals were initially charged -- though many of them have since seen those charges dropped or reduced. While presenting the investigation’s findings on Tuesday to state lawmakers on the House Appropriations Committee, dLCV executive director Colleen Miller spoke about the importance of looking into what happened to Otieno. MORE: New videos shed light on Irvo Otieno’s time at Henrico hospital and jail before in-custody death "After we issued our report, his mother called us to make sure that we understood just how deep a loss they [have] all felt since his death," Miller said before the committee. "And to make sure that we understood that this was something -- in their view -- that cannot continue in Virginia." Miller said that “serious reform” is needed in the Commonwealth because, while these missteps were deadly and received significant media attention, they represent a broader issue. “People with mental illness are encountering these issues every single day in Virginia and we need to do something about it," Miller said. Per the dLCV report, these failures include when Otieno was restrained in a prone, face-down position in the admissions room at Virginia’s Central State Hospital in Dinwiddie County where he died. Miller and the report said that the prone restraint led to Otieno’s death, with Miller telling lawmakers Tuesday that it should be eliminated. A group of Henrico sheriff’s deputies and Central State Hospital workers are seen in video piling on top of Otieno as he’s in the prone restraint position in the admissions room before he is eventually motionless and life-saving efforts that fail are performed. The risky and controversial practice is still used by law enforcement despite “decades of awareness and education on the risks,” the report said. The Henrico County Sheriff’s Office doesn’t have policies regulating the use of the prone restraint, per the dLCV. “When law enforcement placed Mr. Otieno in a prone restraint, Central State Hospital staff joined in that restraint, even though restraining someone face down violates the Human Rights Regulations,” the dLCV report states. “Unfortunately, this was not just a violation of his human rights, but an action that, tragically and avoidably, ended Mr. Otieno’s life.” Other issues that the dLCV found include how long Otieno was kept in a restraint chair once transferred from Parham Doctors’ Hospital to the Henrico County Jail on charges that included assault on law enforcement. Per the report, Otieno was restrained for “at least 17 hours, and possibly up to 40 hours.” While speaking to the committee, Miller said Otieno was left in the chair for at least 11 hours. The report and Miller raised concerns over the escalating effect of law enforcement on Otieno while he was in distress, Parham Doctors’ Hospital’s failure to give him stabilizing treatment, a lack of mental health care for Otieno in Henrico jail and other issues. "This was a tragedy at every level," said Del. Rodney Willett (D-Henrico) on Tuesday. "It seems like every turn, there was a failure." Del. Mark Sickles (D-Fairfax) described the report as "very disturbing" and said that state lawmakers have been working to help deal with the behavioral health system concerns. Sickles pointed to the state's shortage of mental health personnel and housing availability concerns as barriers to properly addressing the ongoing issues. Del. Delores McQuinn (D-Richmond) shared her concerns about law enforcement’s ability to handle these situations and help those experiencing a mental health crisis. She said sheriffs she has spoken to in Richmond and Henrico, two localities she represents, are “overloaded” with people who have mental health challenges and they “really don’t have a clue of what to do with them.” MORE: ‘We don’t want to break people’: Lawmakers, advocates make recommendations after Irvo Otieno’s death McQuinn said that she didn’t think the state’s issues would be solved soon, but would take “some years.” Here are the full recommendations from the dLCV report: Prevent the Criminalization and Unnecessary Incarceration of People with Disabilities Create and expand intervention programs, such as co-responder teams, crisis intervention teams, and mobile crisis teams, led by clinicians and social workers trained to stabilize individuals in crisis Create and expand prevention programs and crisis stabilization units designed to prevent or deescalate behavioral health crises End the practice of arresting and prosecuting an individual for assaulting a law enforcement officer if that individual is currently in a mental health crisis Revise Virginia law to ensure that individuals under a TDO are not diverted from treatment due to incarceration, instead always being sent to an appropriate care provider Implement Adequate Health and Behavioral Health Standards in Jails Officially implement the Minimum Standards for Behavioral Health Services in Local Correctional Facilities as drafted by the 2019 HB 1942 advisory group Strengthen jail healthcare standards, including: adequate healthcare staffing, access to medications, timely hospital transfer and continuity of care, and improved screening Create a strict standard for the use of mechanical restraints in jails to reflect clinical best practices and restrictions Ensure that individuals receive timely access to medical and mental health appointments, including the immediate ability to request medical and psychiatric services Create a local and regional jail ombudsman to handle complaints by inmates, staff, and the public Amend the Virginia Code to explicitly state that the Board of Local and Regional Jails has the authority to sanction facilities that fail to meet minimum standards or engage in egregious conduct Protect the Rights of Patients in Hospital Settings to Ensure Necessary Care Revise Virginia law to ensure that medical providers are able to use their discretion to protect patients and their rights even in the presence of law enforcement Organize local hospital and law enforcement partnerships to workshop protocols and guidelines to reduce custody confusion, ensure patient care, and maintain public safety Have the Virginia Department of Health create and dispense a toolkit to guide hospitals in developing clear policies for interaction with law enforcement centered on patient privacy and care Create a standard that ensures patients experiencing a mental health crisis in the Emergency Department are triaged and provided stabilizing treatment within a prompt timeframe Strengthen Police Oversight and Regulate the Use of Prone Restraint Revise Virginia law to ban the use of dangerous restraint techniques that have contributed to the deaths of people in custody, including prone restraint Establish a statewide use-of-force standard for law enforcement with penalties such as discipline and decertification, ensuring that law enforcement groups only authorize the minimal amount of force necessary to accomplish a lawful objective and only after exhausting alternatives to use-of-force Create a legislative standard for uses lethal force that explicitly prohibits deadly force against a person who only poses a risk to themselves or property and that incorporates express de-escalation requirements Expand Virginia’s data collection of use-of-force by police to include disability as a demographic factor Task the Attorney General’s office to prioritize public complaints of police misconduct during the ECO/TDO process Miller explained on Tuesday how the dLCV worked to collect and compile the information contained in the report. Its investigators accessed records from Parham Doctor's Hospital, the Henrico County Jail, the Henrico County Community Service Board (CSB) and Central State Hospital. This was in addition to publicly available records and news reporting, which included security footage. According to Miller, some entities did not cooperate with the investigation, meaning the dLCV "did not get everything [it] wanted." She did not specify which agencies this included.